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Cognitive Behavioural Treatment of Post Traumatic Stress Disorder SVEIKI Jill Schofield Miriam Grace Granthier Training Overview DAY ONE: Understanding and Assessing PTSD DAY TWO: Treatment Strategies for PTSD DAY THREE: Treatment continued, Post Traumatic Growth and Vicarious Traumatisation. Post Traumatic Stress Disorder – Introduction • As the name implies, posttraumatic stress disorder occurs only after (post) an extremely stressful event (trauma). • In the aftermath of a traumatic event, it is normal to have feelings of detachment or emotional numbness, a feeling of distorted or altered reality, amnesia or even repeated reliving of the event. • For most, these feelings will fade within the next few weeks. For others, they become a part of life – when the symptoms last longer than one month we begin to conceptualise this as a disorder. PTSD The more severe the trauma and the longer the person is exposed to it, the greater the likelihood of developing PTSD. PTSD is only diagnosed after: a) a person has been exposed to an extreme trauma; b) symptoms develop that last at least one month; c) the symptoms create extreme distress and dysfunction. It is not certain why particular reactions occur to traumatic events, but they appear to be influenced by at least three important variables: 1. The traumatic nature of the incident. 2. The character and personality of the individual involved – what else is occurring in their life at the time. 3. The preparation of the individual, and the support given before, during and after the event. How does PTSD present? There are three main categories of PTSD symptoms, and all three must be present for the diagnosis of PTSD. 1. Cognitive - re-experiencing the trauma e.g. flashbacks, nightmares, intrusive memories, inability to remember parts of the trauma, dissociation. 2. Emotional and behavioural e.g. exaggerated emotional reaction or detachment (no reaction) to triggers, feeling different, strange or unreal, numb, losing interest and avoiding activities or places that remind the person of the trauma. 3. Physiological - heightened arousal state e.g. physical reactions to triggers, difficulty sleeping, irritability, hypervigilance and exaggerated startle response. PTSD Re-experiencing the trauma Re- experiencing the trauma can take the form of recurrent images, thoughts, and dreams or "flashbacks" of the event. Even reminders of the event can cause extreme distress, so many people go out of their way to avoid places or events that resemble the traumatic event in some ways. Many experience increased anxiety, restlessness, sleeplessness, irritability, poor concentration, hypervigilance or an exaggerated startle response. Some are even plagued by feelings of "survivor's guilt," because they survived when others did not or because of certain things they may have had to do to survive. Guilt Variables • • • • • Responsibility Justification for actions Violation of values Forseeable Preventable Other common manifestations General sleep problems – nightmares? Memory problems Omen formation (I knew it was going to happen) Domino effect – other bad things will happen Anxiety New fears Self harm Tearfulness and depression Clinginess even adolescents Substance/alcohol misuse Regression – e.g. toileting and feeding Complex PTSD Type one trauma– single, simple trauma e.g. RTA Type two trauma– complex recurrent e.g. abuse Complex PTSD Who gets PTSD? Always Those who had an intense reaction at the time Those that thought they were going to die Likely With previous psychological problems Closer to event Closer to victim With other psychological problems With subsequent stressful life events Without social support Sometimes Poorer families PTSD - General Points Event Characteristics - Assault trauma has highest incidence of PTSD. - Man made trauma has higher incidence over natural disaster. - Prior exposure to trauma = vulnerability factors Cultural Factors • Mediates what is considered/perceived traumatic • Mediates victim’s response • Mediates society’s response to victim • May challenge professionals beliefs and ethical codes History of PTSD Soldiers Heart – 1862 American Civil War Railway Spine – 1866 John Erichsen Neurastheniac – 1869 G. Beard & E. Van Deusen Disordered Action of the Heart ‘Effort Syndrome’ – 1891 Boer War. Shell Shock – 1912 Dr Octave Laurent War Neurosis – 1916 World War 1 Battle Neurosis – 1940 World War 2 Lack of Moral Fibre – 1940 Royal Air Force Old Sergeant Syndrome – 1950 Korean War Combat Fatigue – 1961 Vietnam War Transient Situation Disturbance – 1968 Medical Journals Battleshock – 1982 Brigadier Peter Abraham Post-Traumatic Stress Disorder – 1979 Vietnam War Veterans Gulf War Syndrome – 1993 Media Reports History of PTSD - DSM • 1980 - PTSD included in the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-III). • This highlighted a significant change in the understanding of PTSD. • It was now understood the cause was outside the individual (i.e., a traumatic event) rather than an inherent individual weakness (i.e., a traumatic neurosis). History of PTSD – Revisions to the DSM DSM-IV Diagnostic criteria for PTSD included a history of exposure to a traumatic event and symptoms from each of three symptom clusters: • intrusive recollections, • avoidant/numbing symptoms, and • hyper-arousal symptoms. . A fifth criterion concerned duration of symptoms A sixth criterion stipulated that PTSD symptoms must cause significant distress or functional impairment. History of PTSD – Revisions to the DSM • DSM-5 (2013) - PTSD is no longer categorized as an Anxiety Disorder. • PTSD is now classified in a new category, Trauma- and Stressor-Related Disorders, in which the onset of every disorder has been preceded by exposure to a traumatic or otherwise adverse environmental event. DSM-V Criteria: PTSD A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s) 2. Witnessing, in person, the event(s) as it occurred to others 3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless the exposure is work related. DSM-V Criteria: PTSD B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surrounding). 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). DSM-V Criteria: PTSD C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: 1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories thoughts, or feelings about or closely associated with the traumatic event(s). DSM-V Criteria: PTSD D. Negative alternations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”). 3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). 5. Markedly diminished interest or participation in significant activities. 6. Feelings of detachment or estrangement from others. 7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). DSM-V Criteria: PTSD E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects 2. Reckless or self-destructive behavior 3. Hypervigilance 4. Exaggerated startle response 5. Problems with concentration 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). DSM-V Criteria: PTSD F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. The disturbance is not attributable to physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Coexisting Conditions • 60-100% of PTSD suffers meet criteria for at least one other Axis I disorder., including: • Common Axis II Disorders • Borderline • Antisocial • Major depression • Substance abuse • Panic disorder, agoraphobia • OCD • Social Phobia • Paranoid • Schizoid personality disorder CBP understanding of PTSD Evolutionary Context “…converging evidence in experimental and social psychology and in neuro physiology suggest that much of the processing involved in the generation of emotional experience occurs independently of, and prior to, conscious, deliberate, cognitive operations. Therefore working at the purely conceptual level to effect emotional change may not produce enduring change. Instead, therapeutic interventions are more likely to succeed if they target the schematic processes that automatically generate the emotional experience that underlies clients’ felt sense of themselves. “ Gilbert, p79 2004 Bringing Explanatory models Together • Many practitioners use a synthesis of models to understand PTSD to explain it to clients and to treat it. • Mowrer 1947 2 factor theory – classical and operant conditioning Avoidance of conditioned stimuli (trauma memory and triggers) in order to avoid conditioned responses (fear and anxiety) leads to symptom maintenance through negative reinforcement. Cannot explain intrusions. • Foa and Rothbaum 1989 ‘fear network’ stimuli, responses and meaning encoded peri traumatically. Stable and generalised - activated by anything associated with the trauma - leads to avoidance behaviour –an information processing model – suggests exposure to the memory in safe environment will lead to habituation – decrease in emotional response, allow spontaneous changes to meaning and reduce generalisation of stimuli. Adaptation Foas Schematic model of Pathological Trauma Memory network Me Say Poor dog Assault Alone Man Park Dog Take sweets Cry Bike Rain Track suit Freeeze PTSD symptoms Confusion Stupid Danger False associations between harmless stimuli fear network Bringing Explanatory models Together - Social Cognitive • Horowitz ‘completion tendency’ 1986 – brain integrates information with existing beliefs and will keep re-presenting data (intrusions) until integration complete. Person will move between an integration mode and avoidance mode, when exposure to memory and intrusions becomes too emotionally aversive. • Janoff Bulman 1985 constructivist model– shattering of previous world view. – More likely in people with rigid view whether optimistic or pessimistic (Foa 1996) – Particular beliefs may be important predictability, controllability. Also safety, trust, power, esteem , intimacy (Mcann and Pearlman 1990). • Resick and Schnicke (1992) affect can include shame, anger, sadness due to appraisal. Need to challenge faulty appraisals to lose affective disturbance. Shattered Worldview Janoff Bulman 1985 World is safe Dogs keep you safe Nice people have dogs I am smart I am ok Adults help you Nothing bad ever happens to me Other people are kind I can look after myself Bringing Explanatory models Together 3 - Multi level Processing • Interacting Cognitive Subsystems ICS Teasdale and Barnard (1993) complex information multi level processing – reliving. • Ehlers – ‘hotspots’ 2005 - moments of greatest distress in trauma memory/intrusions. Alternative appraisal inserted into trauma memory either by imaginal exposure and rescripting, reading narrative whilst thinking also of new appraisal. If imaginal not enough then performing actions that provide information and sensory cues incompatible with the original meaning when focusing on the “hot spot” (e.g., walking about if patients thought that they were paralysed, looking at a recent photograph of themselves if they thought they died during the traumatic event). Ehlers & Clarke. (2000) A Cognitive Model of posttraumatic stress disorder. Characteristics of trauma / Sequelae Prior Experiences/ Beliefs/ Coping State of individual Cognitive Processing during Trauma Influences Nature of Trauma Memory Negative Appraisal of Trauma and / or its Sequleae P E R S I S T E N T Matching Triggers Current Threat Intrusions Arousal Symptoms Strong Emotions Strategies Intended to Control Threat / Symptoms Arrows indicate following relationships: © Think CBTthe Ltd. [email protected] Influences01732 = 808 626 www.thinkcbt.com Leads to = Prevents change in = P T S D Maintenance Cycle Memory not processed integrated Memory/thought actively suppressed and/or avoided Intrusive memories, thoughts, Nightmares, images Re-experience original horror, fear, helplessness Integrative Cognitive Subsystems ICS Teasdale and Barnard (1993) – Attempts to address issues of: • Memory • Variability within schema over time • Return to normal of dysfunctional thinking with no direct cognitive intervention • Environmental factors within aetiology • Emotional and cognitive levels of meaning • Using research from information processing models of mind The ICS Model Limb Proprioceptive Object Image Visual Hue, bright Propositional Behavioural Acoustic Tone Peripheral Emotional & Consequences Implicational Articulatory Move Morphonolexical Speech, & language functions Previous learning experiences, genetic, cultural, social and environmental influences. The current environment 7 Front Systems – – – – – – – Limb: proprioceptive information Peripheral: taste, touch, smell Visual: brightness, hue and colour Acoustic: pitch, tone and sound properties Articulatory: movement Object: visual imagery Morphonological: speech meanings 2 Central Systems – Propositional: the smallest individual units that can convey meaning. Words as descriptors of objects. – Implicational: abstract thoughts and emotional connotations attached to meanings. ICS Definitions and Systems PERIPHERAL SUBSYSTEMS a) Sensory coding dimensions (1) Acoustic (AC): Sound frequency (pitch), timbre, intensity etc. Subjectively, what we ‘hear in the world’. (2) Visual (VIS): Light wavelength (hue), brightness over visual space etc. Subjectively, what we ‘see in the world’ as patterns of shapes and colours. (3) Body State (BS): Type of stimulation (e.g., cutaneous pressure, temperature, olfactory, muscle tension), its location, intensity etc. Subjectively, bodily sensations of pressure, pain, positions of parts of the body, as well as tastes and smells etc. PERIPHERAL SUBSYSTEMS b) Effector coding dimension (4) Articulatory (ART): Force, target positions and timing of articulatory musculatures (e.g., place of articulation). Subjectively, our experience of subvocal speech output. (5) Limb (LIM): Force, target positions and timing of skeletal musculatures. Subjectively, ‘mental’ physical movement. CENTRAL SUBSYSTEMS c) Structural coding dimensions (6) Morphonolexical (MPL): An abstract structural description of entities and relationships in sound space. Dominated by speech forms, where it conveys a surface structure description of the identity of words, their status, order and the form of boundaries between them. Subjectively, what we ‘hear in the head’, our mental ‘voice’. 7) Object (OBJ): An abstract structural description of entities and relationships in visual space, conveying the attributes and identity of structurally integrated visual objects, their relative positions and dynamic characteristics. Subjectively, our ‘visual imagery.’ d) Meaning and two semantic codes (8) Propositional (PROP): A description of entities and relationships in semantic space conveying the attributes and identities of underlying referents and the nature of relationships among them. Subjectively, specific semantic relationships (‘knowing that’). (9) Implicational (IMPLIC): An abstract description of human existential space, abstracted over both sensory and propositional input, and conveying ideational and affective content: schematic models of experience. Subjectively, ‘senses’ of knowing (e.g., ‘familiarity’ or ‘causal relatedness’ of ideas), or of affect (e.g., apprehension, desire). Propositional – twig / snake https://www.youtube.com/watch?v=gw d-wLdIHjs Evolutionary Context Le Doux 1996 suggest there are two processing routes – quick and dirty (low road) crude amygdala fear appraisal leading to an automated alarm signal to the brain and body that sparks off freeze/ fight/ flight responses and Clean and slow (high road) where same data comes through the thalamus and neo cortex Conscious recognition of flight and fight ‘switch on’. The short amygdala route works twice as fast the thinking neo cortex often too slow to prevent the generation of emotional response e.g. amygdala spider threat – neo cortex, ‘ it’s the stem of a tomato no need to panic’. Schematic Propositional Associative Analogue Representational systems Approach (SPAARS) APPRAISAL SCHEMATIC MODEL LEVEL Survival goal threatened Bear EVENT ANALOGUE LEVEL Image of Bear in Woods PROPOSITIONAL LEVEL “The Bear will eat me” INTERPRETATION EMOTIONAL PRODUCTS and OUPUT SYSTEMS Schematic Propositional Associative Analogue Representational Systems Approach (SPAARS) – Goal directed – Multi level theory SPAARS 1 = Propositional Route SCHEMATIC MODEL LEVEL 2= Direct Analogical Route ANALOGICAL LEVEL Bodily sensations 2 ASSOCIATIVE LEVEL 1 1 SPARRS AND PANIC PROPOSITIONAL LEVEL “I am feeling dizzy and will faint” PRODUCTS OF PANIC Implications for Practice – Meta models which can be used to understand many different disorders, PTSD, OCD, Panic, Anxiety States, Phobias etc. – Understanding of theories can aid functional analysis of clients difficulties – Understanding of memory functions and processes can be used to explain differences between cognitive & emotional knowing – Negates intra-psychic blaming of client – Gives account of uses of emotional states ACTIVITY 1. CASE STUDY Shane is a 24 year old single man who lives with his parents. His father is an alcoholic with a history of violence to his family. Shane has over the last two years following a road traffic accident started to dissociate in response to any life stressors and over the last year he has started to self harm as a way to reduce his anxiety and stress. There are no symptoms of PTSD, but he does report feeling low in mood. FORMULATE THE ABOVE USING ICS AND SPARRS – Be creative as to other background details etc Time 20 minutes ACTIVITY 2. Therapy PLAN Based on your formulation for SHANE: 1.Draw up a therapy plan. 2.Consider the issue – do the different theories lead you to come up with the same or similar strategies? 3.What do these formulations add to more disorder specific formulations? ACTIVITY - Identify a case complex case that you are working with, then critically evaluate the formulation or theory that you have used by using either SPAARS or ICS. - Reformulate the case and draw up the therapy plan. - Consider the similarities and differences. CBP Assessment of PTSD Context Environment must be safe. ‘Obvious empathy’. Share anger, horror, disgust Therapist should be comfortable with the details. Containing. Identify concerns re ‘burdening’. Sessions longer when doing reliving. Supervision and support for therapist is essential. Assessment Comprehensive treatment of PTSD requires thorough and on going assessment Critical in developing appropriate treatment plan Goal of the assessment is to Build rapport To assess PTSD and associated problems Determine and validate clients perception of their problems Avoid overwhelming yourself with information that is not helpful Develop an understanding of the impact on them today – how has their life changed Assessment Current problems: how do they describe their current problems Collate enough information regarding the trauma without going into detail Consequences of the trauma Assess co-morbidity – Axis I ad II Identify the impact, through SUD ratings, on the thought of telling you their story do they connect or disconnect Assessment Main cognitive themes: - Beliefs about themselves, the world and others, - worse thing about trauma? - most difficult thing since trauma? - meaning of having PTSD? - main feelings? - appraisal of ongoing threat? Explore ‘hot spots’: - when most distressed - moment when patient dissociates Assessment Maintaining factors: - coping with intrusions - avoidance / triggers to re-experiencing symptoms and high affect. Safety behaviours: - attempts to control symptoms - attempts to evade feared catastrophe Assessment • What do they understand about PTSD? • Explore how they think that the trauma has effected them • What does it mean to them to have PTSD? • What are their main feelings? • What is their appraisal of ongoing threat? • The impact on relationships, work and other activities PTSD Assessment • Assess if the trauma has been processed, cognitively, emotionally and physically. Including: • Intrusive memories • Flashbacks / disassociation • Nightmares • Intrusive images PTSD Assessment Assess if the trauma has been processed, cognitively, emotionally and physically. Including: Intrusive memories Heightened arousal Flashbacks / disassociation Hypervigilent to danger Nightmares Intrusive images Startle response Feeling numb PTSD Assessment • • • • Culture Reservations about treatment Legal proceedings Other agencies • Goals Measures Impact of Events Scale Revised – Horrowitz The IES-R is a 22-item self-report measure that assesses subjective distress caused by traumatic events Items correspond directly to 14 of the 17 DSM-IV symptoms of PTSD. Respondents are asked to identify a specific stressful life event and then indicate how much they were distressed or bothered during the past seven days by each "difficulty" listed. The IES-R yields a total score (ranging from 0 to 88) and subscale scores can also be calculated for the Intrusion, Avoidance, and Hyperarousal subscales Impact of Events Scale Revised Item Response Anchors are 0 = Not at all; 1 = A little bit; 2 = Moderately; 3 = Quite a bit; 4 = Extremely. The Intrusion subscale includes questions 1, 2, 3, 6, 9, 14, 16, 20. The avoidance subscale includes questions 5, 7, 8, 11, 12, 13, 17, 22. The hyperarousal subscale includes questions 4, 10, 15, 18, 19, 21. See hand out CBP Treatment of PTSD Contraindications for therapy Behaviourally or emotionally very unstable: - suicidal / homicidal - very high levels of substance misuse - significant anger control issues - ongoing risk (you cannot discriminate if it is still going on), including asylum seekers who may be sent back - battered women still living with perpetrator -occupations / subgroups at a very high risk of further trauma - Active psychosis -Medico – legal demand for treatment without desire to engage for other reasons Treatment of PTSD Many methods of therapy have been developed for survivors of trauma. All methods share the following guidelines: Therapy is individualized to meet the specific concerns and needs of each unique trauma survivor, based upon careful interview and questionnaire assessments at the beginning of (and during) treatment. Therapy focusing on the traumatic event is only carried out when the person is not in crisis. If a person is severely depressed; suicidal; experiencing extreme panic; high levels of dissociation; in need of drug or alcohol detoxification; or currently exposed to trauma such as by ongoing domestic violence, then these issues should be addressed first. Treatment of PTSD There are four main principals of CBP treatment: Providing information on the nature, etc., of PTSD in the early stages can be very useful and contribute to normalisation. Exposure (live & imaginal) – aims to evoke anxiety and promote habituation. The exposure is to the memories of the event itself as well as other avoided areas, e.g., the scene of the road traffic accident. Cognitive restructuring – aims to modify automatic negative thoughts, dysfunctional beliefs, etc. Anxiety management techniques – aims to teach the person a variety of coping skills in order to manage anxiety and other symptoms. Treatment – general plan Socialising to treatment Re-engage with life Processing the trauma – If appropriate at this stage Anxiety management training / Exposure Cognitive restructuring Relapse Prevention Treatment plan continued If required work is undertaken prior to processing trauma Managing Dissociation Working with Flashbacks Dual awareness Socialise to Treatment Rationale for treatment initial symptoms are a normal reaction to a traumatic experience. initial coping strategies can act to maintain symptoms. treatment involves reversal of maintaining symptoms. Socialise to Treatment Education - normalise - explain how memory works - demystify procedures during / after trauma e.g. how Paramedics /Police work; how drugs work; explore effects of injury on processing Socialise to Treatment Thought suppression - how - why - behavioural experiments Strategies for dealing with intrusions monitor quality and frequency of intrusions (take a baseline) *Need to identify if the client is fearful that not suppressing intrusions will lead to panic. Re-engaging with life • Re- engage as soon as possible • identify and problem-solve obstacles • identify strategies to control avoidance • identify and begin to reduce safety behaviours Processing Trauma Patient must be in a reasonable state to benefit: - Alert - Sober - Not facing unusual other stressors Therapist needs to carefully balance full activation of memory and emotions with spotting meanings and unhelpful strategies used whilst reliving. Processing Trauma Structure Sessions 1-2 imaginal exposure to the entire event adding more and more detail Session 3 identify critical points (Hotspots) Sessions 4-6 Imaginal exposure to critical points Function of Reliving Promotes elaboration and contexualisation of trauma memory Helps with identifying idiosyncratic appraisal of trauma Decreases fear of the memory Facilitates discrimination between now and then Reliving Reliving - Provide rationale -Replay as realistic as possible (eyes shut, in present tense). Help patient focus / ‘stay with it’. -Become aware of as much detail as possible. -Demonstrate your support and empathy Reliving • Client relives the traumatic event First Person, present tense Include stimuli, response, meaning elements All sense modalities Rewind and hold Prolonged Audio-taped Reliving Start with entire event, then move onto ‘hot spots’ ‘Debrief’ from reliving - Distress ratings (beginnings, end, hot spots’) - Vividness rating - Identify most troublesome feelings - Meanings - Reorient patient to current place and time Reliving - Ask client to close eyes - 4-5 sessions - 1st person / present tense - After initial session, ask what client did to distance themselves - Record the reliving Reliving Making reliving work well Clients should have: fully understood and agreed with the rationale; feel safe, in control, be behaviourally reasonabl stable; have made preparations for the immediate reaction to reliving. Treatment of PTSD - May cause 50-60% of patients to have worse nightmares / intrusions initially - If client has other major stressors, reliving exposure can be postponed - Reliving elicits shame / guilt responses Eye movement Desensitisation and reprocessing (EMDR) Developed in 1989 by Francine Shapiro. At the heart of EMDR is the notion that accelerated processing of disturbing material can be directly facilitated at a neurophysiological level using a variety of dual attention tasks. A by-product of resolution at this level is cognitive and emotional well-being. NB: This procedure should not be attempted without specific training. Eye movement Desensitisation and reprocessing (EMDR) • In 1987, Dr. Shapiro was taking a stroll in the park and had some disturbing thoughts flash through her mind. After moving her eyes from side to side she noticed the negative feelings immediately dissipate. She assumed that the eye movements had a desensitizing effect. • Eye Movement Desensitization (EMD) was introduced in 1989, later called (EMDR) Eye Movement Desensitization and Reprocessing (1991) to reflect the cognitive changes that occur during treatment and to identify the information processing theory. Eye movement Desensitisation and reprocessing (EMDR) • When an individual becomes upset or in distress, the brain cannot process the information as it would normally. • Some traumatic event or recurring situation provokes intense emotions that become “frozen in time” and “stuck in the information processing system. • Dr. Shapiro claims EMDR has a direct effect on the way the brain processes upsetting material. Eye movement Desensitisation and reprocessing (EMDR) • No one can explain how it works. • You concentrate on a problem and move eyes by following a stick, a light, or a finger. • Some say it unblocks the information processing system. • Others say it workby the restructuring of memory by a ping-pong effect between the rights and left side of the brain. • It affects how the brain interprets upsetting materials The Eight Phases of EMDR 1. Client’s readiness for EMDR is assessed - Treatment plan is laid out 2. Make sure client has coping skills and is in a relatively stable state Stress-reducing techniques taught and mastered Phase 3 through 6 • Target is identified and processed using EMDR. • Client identifies positive beliefs and rates it from 0-10. • Client focuses on the image, negative thought, and body sensations while moving eyes back and fourth following the therapist’s finger. • Client instructed to notice whatever happens and let their mind go blank and then notice thoughts, feelings, images, memories, or sensations that come to mind. • When client reports no distress related to the targeted memory clinician asks them to think of preferred positive beliefs. • Therapist checks with client regarding body sensations. Phases 7 and 8 7. Closure Client keeps a journal 8. The Next Session Re-evaluation of work done and inquire about progress made Image Re-scripting Imagery - focussed treatment designed to alleviate PTSD symptoms and alter abuse-related beliefs and schemas e.g. powerlessness, victimisation, inherent badness, unlovability, intolerability Image Re-scripting 9 Sessions (90 minutes to 120 minutes) Fully informed clients Information gathering, including suitability Treatment rational Exposure phase - imaginal re-enactment of the trauma in its totality Image Re-scripting Imaginal or reliving work includes verbalising aloud what she or he is experiencing. Therapist must be supportive but encourage the client to stay with the effectively changed imagery. Image Re-scripting Re-scripting phase - incorporates into the imagery a new scenario in which the adult self enters the abuse scene to assist the child. Role of the adult is: - rescue the child and protect from further abuse -drive out the perpetrator (with others if necessary) Therapist remains non directive – socratic. Image Re-scripting Ideographic measurement Rate 0-100%: - to drive the perpetrator away - adult to nurture the child - vividness of the imagery Rest of session devoted to processing the session and homework. A recording of the session is made and should be reviewed twice daily for homework, SUDS are rated and episodes of PTSD reactions recorded . Anxiety management Relaxation Exposure preparing them for exposure Construct a fear hierarchy Explain habituation Cognitive Restructuring To teach the client how to systematically replace unhelpful thoughts with more helpful and realistic thoughts Relapse Prevention Relapse prevention in relation to maintaining improvement; handling future trauma; managing urges to use alcohol and drugs, etc. What is Dissociation “Dissociation is the act of separating something from your awareness. It is an important defence mechanism that everyone has against becoming overwhelmed by the noise and visual chaos of daily life. When things get too much, we simply switch off pieces so we don't have to hear them, see them, or know about them. Usually we don't actually decide to do this. Our brain does it automatically for us. When a child is being overwhelmed by the pain and fear of some traumatic event like being beaten up or raped, she may use dissociation to mentally escape a situation which she can not escape physically. Children are especially good at this”. Lambert, (2006) Methods to Reduce Dissociation Dissociative disorders might not be uncommon. Rates as high as 11% in the general population (Ross, 1991) 15% in Psychiatric patients (Sax et al., 1993) 88% in survivors of childhood sexual abuse, (Anderson, Yasenik & Ross, 1993) Methods to Reduce Dissociation Dissociative Amnesia – may be present when a person is unable to remember important personal information, usually associated with a traumatic event. Dissociative Fugue – may be present when a person impulsively wanders / travels away from home and upon arrival in a new place is unable to remember their past. Depersonalisation Disorder – feelings of detachment or estrangement from one’s self or others. Dissociative Identity Disorder (DID) – formerly known as Multiple Personality Disorder (MPD). Methods to Reduce Dissociation For those who are able to access psychological, emotional and/or somatic events during dissociation, the content of flashbacks or traumatic memories can also be established in the assessment. Kirk, (1989) argues this can an be achieved through: - Diary Keeping; - Interview; - Observation in session or by significant other. Methods to Reduce Dissociation Outward signs of dissociation may be subtle: - discrete movements such as tapping, rubbing a limb, or gently rocking of the body. Clients are often fearful of affect or mistrustful of others. It can be helpful to ask, “What will make this easier for you”? Methods to Reduce Dissociation Managing Triggers and Reactions With complex presentations, invest time in building a working alliance /creating a safe environment for the cognitive work to take place. Identify triggers, e.g. painful affect such as profound sadness / or intense anger and predictions of not being able to cope; perceptions of dangerousness; perceived sexual talk or behaviours. Methods to Reduce Dissociation Planned Avoidance: Once triggers for dissociation are predictable, plans can be made to avoid particular situations or persons. This can help generate a sense of relief and perhaps a sense of mastery and safety. They can later choose whether or not to embark on an exposure to the trigger(s). Planning, distraction and grounding skills can help arrest the process of dissociation. Methods to Reduce Dissociation Distraction Techniques Can be used at an early stage to arrest an unpleasant dissociative experience. Refocusing: Client is required to concentrate hard on some aspect of the environment such as the colour / texture of curtains, the feel of the arms of a chair, titles of books on shelf etc. Methods to Reduce Dissociation Grounding Words: An agreed word which brings client back to the present. Clients name often fulfils the function, (but check that name is not one which evokes traumatic childhood memories). Word could also be a place of work, the current date, a partner’s name etc. Methods to Reduce Dissociation Grounding objects: Tangible and portable objects which are pleasant and associated with the present, e.g. small, soft toys, ‘stress balls’ or wooden eggs. Herb bags can be particularly potent because of the smell they emit. Methods to Reduce Dissociation Grounding Images: Mental image of a safe and soothing place. Should gain be clients choosing and comprise as many sensory modalities as usual. More absorbing if it also contained an enjoyable routine. Images however need rehearsing frequently and associated with a relaxation exercise. Methods to Reduce Dissociation Grounding Phrase: Brief sentence or mantra which reminds client of themselves in the present and can be practised until it comes to mind regularly. Should be emphasised to the client that all these strategies need to be over-rehearsed if they are to be accessible during times of high stress and vulnerability. Methods to Reduce Dissociation Cognitive restructuring to diminish the ‘predictive’ power of the trigger and negative meaning of dissociative reaction, e.g. “I must not feel emotion, this is a sign of weakness” Education on nature of cognitive distortions, e.g. dichotomous thinking, catastrophic prediction, overgeneralisation etc. Methods to Reduce Dissociation Graded Exposure: Through learning grounding skills and ways of managing dissociation. Initial stages of exposure will promote significant anxiety and grounding skills are used simply as a way to tolerate emotions in a controlled way. Potentially use imagery first to promote feared emotional state, grounding skills utilised to desensitise client. Methods to Reduce Dissociation Develop a hierarchy of feared situations, thoughts, images etc. Wherever possible, in vivo exposure should be practised. The process may be prolonged in most severe cases. Treatment of PTSD Process and relationship Clear treatment rational Engagement Collaborative relationship Clinical setting Obtain feedback Homework setting and closure Treatment of PTSD Engagement Initially expect motivation to be poor Increase motivation by: Credible rational Reinforcement of help seeking behaviour Explicit pros and cons of treatment and solutions Finish sessions with short term goals Treatment of PTSD Difficulties in treatment: Non-engagement Depression Guilt Anger Pain Injury Bereavement Vicarious traumatisation Working with Flashbacks Grounding and Monitoring Toolkit Putting on the brakes 5 senses including object Safe place Reality testing Anchoring ANS arousal vigilance Breathing Grounding Dual awareness Why learn to ‘put on the brakes’? 1. SAFE AND EFFECTIVE PRACTICE: To ensure that the trauma is being processed and not retraumatising the client 2. CLIENT EMPOWERMENT AND RESPONSBILITY To teach the client the skills so that they can choose when to process the trauma and when to contain it. This restores their confidence in their own ability to judge what is right for them, to control and monitor themselves. Safe Place Creating a safe place: Sight Sound Touch Smells Taste Body Awareness Anchoring Deepen the experience Anchoring points Experiential exercise Breathing to ‘ground’ Teach breathing Invite client to breath Breath noticeably yourself and / or encourage client to breathe with you Invite them to feel feet on ground or to imagine breathing up through their feet Objects to ground Soft objects as less useful than objects with a rough texture. Fir cone Velcro Rough shell Using the senses If the client appears to dissociate, use the 5 senses. You need a minimum of 2 senses to be present within the client in order to know the client is not dissociated beyond contact / psychotic. E.g. ‘Nod your head if you can hear me.’ (tests both movement and hearing) Reality Testing Are you safe now? How likely is it that this will happen again? Importance of Body Awareness To be able to work effectively the therapist needs to know when the client’s ANS arousal is high as this indicates whether the client’s flight or fight response is switched on. If their fight or flight response is switched on then the processing is not taking place in the neo-cortex / hippocampus as the amygdala is dominant. Arousal vigilance Monitoring the client’s physiology helps the therapist to know how the processing is going and whether to continue process or to stop and return to a safe place or different conversation. Over time the client will come to learn to do this for themselves. Monitoring arousal using the body Discuss with the client their own awareness of arousal symptoms and ask them to grade the feelings on a scale of 1-10, inviting them frequently to report on what level the feeling is. Watch the client’s breathing, body movement or lack of movement, changes in skin colour, loss of eye contact, inability to hear or respond. Dual Awareness Dual awareness is taught by Dr. Babette Rothschild and can be found in her book, The Body Remembers. Psychological tools that were missing to meet the overwhelming trauma are also usually missing to meet the overwhelming flashback; otherwise it would not be a flashback. Integration under those circumstances was and is not possible. Dual awareness is a tool to help prepare the client to be able to process and integrate trauma. What is Dual Awareness? • When a client goes into flashback it is a sign that the client’s experiencing self (i.e. their behaviours and emotions) is having free rein. • Under these circumstances, the client’s observing self (their cognitions) must be awakened and called back into the therapy room usually with a measure of authority (firm, but not angry) from the therapist: ‘Look at where you are now. What colour is the wall here? What colour is the rug? What kind of shoes do you have on right now? What is today's date?’ etc. What is Dual Awareness? •When the client has experienced the return of their cognitions or observing self the flashback halting protocol can be taught so that they can practice the same process on their own. It is based on the principles of dual awareness, reconciling the experiencing self with the observing self. The client slows down their associative emotional response from ‘quick and dirty’ (SPAARS model) to allow the neo-cortex to catch up. Flashback Halting Protocol This usually will stop a traumatic flashback quite quickly. The client says, preferably aloud, the following sentences filling in the blanks and following the instructions. • Right now I am feeling…….. Insert name of the current emotion, usually fear • and I am sensing in my body……… Describe your current bodily sensations – Name at least three • because I am remembering………. Name the trauma by title only – no details Flashback Halting Protocol • At the same time, I am looking around where I am now in….. The actual current year • here…… Name the place where you are • and I can see…… Flashback Halting Protocol • Describe some of the things that you see right now in this place • and so I know……. • Name the trauma by title only again • is not happening now/anymore. Symptoms of ANS Arousal • • • • • • • Body Awareness Body Scan (relaxed) Experiential Exercise Body Scan (aroused) Experiential Exercise Symptoms of ANS Arousal • • • • • • • Power poses Using neuroscience to change body chemistry • Reduces cortisol • Increases testosterone Amy Cuddy link http://www.ted.com/talks/amy_cuddy_your_body_languag e_shapes_who_you_are?language=en Relaxing and tensing Relaxing releases tension But is by no means the only way to work Tensing and strengthening exercises are found to be useful in improving resilience. Exercise Laughter This also changes physiology and brain chemisty. Post-Traumatic Growth Post-Traumatic growth ‘Suffering is universal: you attempt to subvert it so that it does not have a destructive, negative effect. You turn it around so that it becomes a creative, positive force.’ Terry Waite Survived four years in solitary confinement, chained, beaten and subject to mock execution. Post-traumatic growth Post-traumatic growth or benefit refers to positive psychological change experienced as a result of the struggle with highly challenging life circumstances. The term posttraumatic growth was introduced by two pioneering scholars Richard Tedeschi and Lawrence Calhoun. This does not mean that trauma is not also destructive and distressing. No one welcomes adversity. But the research evidence shows us that over time people can find benefits in their struggle with adversity. Indeed, across a large number of studies of people who have experienced a wide range of negative events, estimates are that between 30 and 70% typically report some form of positive change. What Doesn't Kill Us by Stephen Joseph After experiencing a traumatic event, people often report three ways in which their psychological functioning increases: 1. Relationships are enhanced in some way. For example, people describe that they come to value their friends and family more, feel an increased sense of compassion for others and a longing for more intimate relationships. 2. People change their views of themselves in some way. For example, developing in wisdom, personal strength and gratitude, perhaps coupled with a greater acceptance of their vulnerabilities and limitations. 3. People describe changes in their life philosophy. For example, finding a fresh appreciation for each new day and re-evaluating their understanding of what really matters in life, becoming less materialistic and more able to live in the present. People who Have Experienced PostTraumatic Growth Say Five Things 1.) My priorities have changed; I'm no longer afraid to do what makes me happy. 2.) I feel closer to my friends and/or family. 3.) I understand myself better, I know who I really am now. 4.) I have a new sense of meaning and purpose. 5.) I'm better able to focus on my goals and dreams. As McGonigal points out, these are essentially the opposites of the Top Five Regrets of the Dying, which led her to ask herself, "How does trauma unlock our ability to live a life with fewer regrets? How do you get from trauma to growth, or better yet, is there a way to get all the benefits of Post-Traumatic Growth without the trauma?” Resilience There are four kinds of strength or resilience that can facilitate Post-Traumatic Growth, and there are scientifically-validated ways to practice developing these resiliencies. Physical resilience Mental resilience Emotional resilience Social resilience Vicarious Traumatisation 1 What is Vicarious Traumatisation? • How does it happen? • What are the symptoms? 2 Diagnosing Vicarious Traumatisation 3 Preventing / healing Vicarious Traumatisation Vicarious Trauma “There is a soul weariness that comes with caring. From daily doing business with the handiwork of fear. Sometimes it lives at the edges of one’s life, brushing against hope and barely making its presence known. At other times, it comes crashing in, overtaking one with its vivid images of another’s terror with its profound demands for attention; nightmares, strange fears, and generalized hopelessness.” B. Hudnall Stamm, Ph.D. Vicarious Trauma Vicarious trauma is the process of change that happens because you care about other people who have been hurt, and feel committed or responsible to help them. Over time this process can lead to changes in your psychological, physical and spiritual well-being. (Headington Institute) Vicarious Trauma Cumulative –happens over time as you work with survivors of trauma, disasters, people who are struggling. Process of change is ongoing – this is hopeful as it provides opportunities for us to recognize the impact the work has on your lives early and to develop strategies to protect and care for ourselves. Vicarious Trauma Empathy When you identify with the pain of people who have endured terrible things, you bring their grief, fear, anger, and despair into your own awareness and experience. What sort of problems or people do you find it easy (or difficult) to empathize with? What are some ways that caring about people who have been hurt affects you? Vicarious Trauma Feeling committed or responsible to help A commitment and sense of responsibility can lead to high expectations and eventually contribute to feeling burdened, overwhelmed, and hopeless/helpless. It can lead people to extend themselves beyond what is reasonable. How does your commitment and responsibility to your work help you? How might it be hurting you? Vicarious Trauma Understanding risk factors: Personality and coping style Personal trauma history Current life circumstances Social support Agency support extending and receiving assistance Affected populations response or reaction Cultural styles of expressing distress and Spiritual resources Work style – work/life boundaries Professional role/work setting/degree of exposure Signs and symptoms Feeling frustration or anger about a patient’s choices Thinking about a patient outside of work more than you want to Feeling anxious about working with a patient Feeling dread when you anticipate seeing a patient Feeling more worried than you think is necessary about a patient Feeling angry at a patient Feeling de-skilled or incompetent when you meet with a patient Taking on too much responsibility- difficulty leaving work at end of day – stepping in to control other’s lives Signs and symptoms Feeling disconnected or dissociated from the patient, their emotions or the content of the session Having physical discomfort or pain while meeting with a patient, which seems connected with what you’re working on Having other physical reactions to a patient’s stories, e.g. increased heart rate, rapid or shallow breathing, nausea, feeling frozen etc. Feeling traumatized after talking with a patient about specifics of their abuse Wanting to cry during/after meeting with a patient Feeling helpless about your work with a patient Feeling enraged at a patient’s perpetrators Vicarious Trauma can impact people in the following ways: Coping mechanisms become overwhelmed; The effectiveness as a caregiver is reduced; Feeling helpless; Detachment from co-workers not involved in the work; Detachment from family and friends; Shortened tenure as service provider. 154 What are the results of Vicarious Trauma? It contributes to feeling burdened, overwhelmed, and hopeless in the face of need and suffering. It leads people to extend themselves beyond what is reasonable for their own well-being. It can bring changes in spirituality which can, in turn, deeply impact the way a people see the world and their deepest sense of meaning and hope. 155 What is Vicarious Trauma? A gradual process that may unfold over time Cumulative effect of contact with survivors of violence or disaster or other trauma Happens because a person cares (empathizes with people who are hurting ) An individual feels committed or responsible to help and at times, cannot help. 156 Common Signs of Vicarious Trauma Difficulty managing your emotions; Difficulty accepting or feeling okay about yourself; Difficulty making good decisions; Problems managing the boundaries between yourself and others (e.g., taking on too much responsibility, having difficulty leaving work at the end of the day, trying to step in and control other’s lives); 157 Sleeping problems; Isolation and disconnection Nightmares; Substance abuse and high risk behaviors; Intrusive thoughts, memories and flashbacks; Hyper-vigilance; General anxiety and anxiety attacks; Changes in appetite and sex drive; Irritability and depression; Cynicism, negativity, and apathy about life and the world. 158 Who may be most at Risk for Vicarious Trauma? People Who: Tend to avoid problems or difficult feelings Blame others for their difficulties, Withdraw from others when things get hard Have experienced trauma themselves Lack connection with a source of meaning, purpose, and hope 159 Have stress in multiple areas of life Diagnosing Vicarious Traumatisation Inventories, questionaires and scales Eg. • • • • Preventing Vicarious Traumatisation • Understanding the function and impact of mirroring and mimicry • Unmirroring postural unmirroring exercise facial unmirroring exercise • Understanding your own arousal Arousal awareness exercise Conscious Postural Imaging Conscious facial imaging Un mirroring Experiential exercise Other tools for preventing Vicarious Traumatisation Sensory anchors Controlling univited images Physical distance Know yourself and your history Fashion and bling Ocular defense Body edges Strengthening the observor Nurturing / cleansing your workspace Self Care Exercise 1 List three or more things that you will pay attention to during each session 2 List through more things you will do between each session 3 This three or more things you would do at the end of each day or each evening 4 List three or more things that you will do at least one time each week 5 List three or more things that you will do at least monthly 6 Now decide to things who will you discuss these plans with? Self Care exercise step by step List three or more things that you will pay attention to during each session: position facial expression breathing pattern body sensations arousal level areas that need muscle tone self talk 1 List through more things you will do between each session write some notes open the window get a drink go to the restroom wash hands stretch and tone up muscles do a cleansing ritual listen or dance to music eat a snack 2 This three or more things you would do at the end of each day or each evening port client material into a secure container take a shower say evening prayers yell at the car window talk to a friend exercise read the paper watch some TV read a good book change clothes 3 4 List three or more things that you will do at least one time each week get exercise have sex see a movie is it with friends or family do volunteer work not related to my employment get out in nature do something artistic have the weekend free to do fun nurturing things List three or more things that you will do at least monthly see your own therapist talk with the supervisor take a minivacation have or attend a party 5 Now decide to things who will you discuss these plans with? Where will you post your list so that you will see it and be reminded to follow your plan? 6 ACIU